Interpreting high troponin: It's not just for cardiologists anymore
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Jan 012012
 

This nice (and brief) review article on interpreting elevated troponin levels can be summed up by its quote from cardiologist Robert Jesse:

“When troponin was a lousy assay it was a great test, but now that it’s becoming a great assay, it’s getting to be a lousy test.”

Troponin abnormality is set at the 99th percentile in the healthy population. As troponin tests have become more and more sensitive, the absolute cutoff value for “abnormal” troponin has become lower and lower. As you’ve undoubtedly discovered, “abnormal” troponin includes a lot of unhealthy people in a lot of clinical situations that don’t include occlusion of their coronary arteries by ruptured atherosclerotic plaques (severe hypertension, renal disease, myocarditis, severe sepsis, and many more*).

This is a brief article that reviews the physiology and kinetics of troponin release and clearance, and emphasizes the need for serial troponin testing and evaluating the results in proper clinical context. Although in 1,200 words the authors don’t really get you out of all (or maybe any) of the dilemmas of interpreting high troponin levels, it’s a good update and it’s free full text.

Mahajan VS, Jarolim P. Clinician Update: How to Interpret Elevated Cardiac Troponin Levels. Circulation 2011;124:2350-2354. 

* Many conditions other than acute coronary syndrome cause elevated troponin levels; here are most of them, divided into primary cardiac and noncardiac causes:

Noncardiac Causes of Increased Troponin Levels

  • Renal failure
  • Pulmonary embolism
  • Severe pulmonary hypertension
  • Sepsis
  • Severe critical illness
  • Burns
  • Extreme exertion
  • Amyloidosis or other infiltrative diseases
  • Stroke and subarachnoid hemorrhage

Cardiac Causes of Elevated Troponin (besides ACS)

  • Acute and chronic heart failure
  • Myocarditis
  • Cardiac contusion from trauma
  • Cardioversion
  • Endomyocardial biopsy
  • Aortic dissection
  • Hypertrophic cardiomyopathy
  • Aortic valve disease (aortic stenosis or regurgitation)
  • Cardiotoxic drugs
  • Tachyarrhythmia (SVT, V-tach, atrial fibrillation)
  • Bradyarrhythmia or heart block
  • Cardiac surgery
  • Cardioversion
  • Tako-tsubo cardiomyopathy
  • Rhabdomyolysis
  • Stenting or angioplasty (percutaneous coronary intervention/PCI)

 

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  10 Responses to “Interpreting high troponin: It’s not just for cardiologists anymore (Review, Circulation)”

  1. My troponin levels were tested in the ER due to acute chest pains which had subsided by the time I arrived in the ER. I was told I had had a heart attack and was transported to a cardiac care unit at DHMC in NH. Once there, I was told my cardiac enzyme levels were normal but my liver enzymes were elevated. Still I underwent a cardiac cath which showed my heart to be a great shape. My abdominal ultrasound, however, showed gallstones. I was discharged and two days later suffered an excruciating gallbladder attack. I was admitted to the hospital, put on IV pain meds, and had both a CT and MRI scan. I had a badly inflamed gallbladder that was “chock full” of stones. After taking antibiotics to reduce inflammation, I had urgent but not emergent gall bladder removal. The gall bladder was still inflamed and gray and full of stones. Did my inflamed gall bladder cause the elevated troponin?

    • Not directly, and there is minimal chance you have coronary artery disease given your clean cath. The gallstones probably caused significant pain, which caused you to be tachycardic, and thereby raising your troponin.

      • Thank you Brandon. That makes sense, although my ECG sinus rhythms were normal.

        • Hi Brandon and Renee — just to add to and clarify this exchange, PulmCCM does not offer medical advice or a forum for the provision of medical advice, we only provide information from the medical literature. For all medical questions, consult your doctor directly. Thanks :) Matt

          • Thanks Matt. I was asking out of curiosity not for medical advice. It just seemed a lot to go through based on one elevated reading that proved wrong and I was wondering if anyone had had such an experience.

  2. Hello,

    I was hoping someone smarter than me can give me some feedback..I recently went to the ER feeling shortness of breath. Once they checked my vitals, my BP was 200/113. They took blood and the troponin levels were were elevated. The diagnosis was heart attack. I had no chest pain at all. I`m 48 yr old male and thought I was in good health. The echocardiogram & angioplasti were both normal. Did I really have a heart attack or were the troponin levels high due to the high BP/hypertension? They put me on 25mg of Metoprolol to control my BP and it seems to be doing the job.If my heart & arteries look good, why were my troponin levels high?

  3. My wife had what they are calling a heart incident or an arrhythmia on November 28, 2013. They did the Troponin-I test and the first one came back.03 ng.mL the next on 4 hours later came back at .16ng/mL. They immediately shipped her to the Banner heart hospital. The doctor there did not see her until 8 hours later and just asked her a few questions and listened to her breath. They are going to do some tests but they are one week out and some others are 4 weeks out. Should we be concerned and should we look to another doctor?? Or is this normal procedure??

  4. I had a heart attack in April 2012 when Troponin T level was 90, since then it has only dropped to 70, no lower.

  5. I have since had 6 emergency admissions via ambulance to local A&E with resulting Troponin T levels always being high, so if i have this strange anomaly, how do doctors know if i have had MI…
    Recently i was taken in with palpitations, given Amiodarone intravenously, which was for Atrial Fibrillation i was told, now on Amiodarone 200mg tablets, plus many others for life.

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